Network meta-analysis of effects of bariatric surgeries on hemoglobin A1c in overweight/obese patients with type 2 diabetes_Chinese Journal of Evidence-Based Medicine

Authors：

ZHOU Xu ¹ , ZHU Weifeng ¹ , CHEN Xiaofan ¹ , YAN Dongmei ¹ , NIE Heyun ¹ ,  CHEN Jianrong ²

1. Evidence-based Medicine Research Center, Jiangxi University of Traditional Chinese Medicine, Nanchang 330004, P.R.China;
2. Department of Endocrinology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, P.R.China;

Corresponding author：

CHEN Jianrong, Email: j.r.chen@hotmail.com

Keywords：

Bariatric surgery; Obesity; Hemoglobin A1c; Network meta-analysis

DOI：

10.7507/1672-2531.201912073

Video：

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Objectives To compare the effects of different bariatric surgeries on reducing hemoglobin A1c (HbA1c) in overweight/obese patients with type 2 diabetes.Methods Randomized controlled trials (RCTs) of bariatric surgery were systematically searched in PubMed, EMbase, The Cochrane Library, ClinicalTrials.gov, CNKI, WanFang Data and VIP databases from inception to February 20^th, 2019. Two reviewers independently screened literature, extracted data and assessed risk of bias of included studies, then, meta-analysis was performed by using Stata 14.0 software and R 3.6.2 software.Results A total of 24 RCTs were included. Compared with non-surgical treatments, 5 out of 9 procedures significantly reduced HbA1c, and the probability order for the effect was as follows: sleeve gastrectomy with transit bipartition (SGTB) (MD=−3.60%, 95%CI −5.89 to −1.31, P=0.002), mini-gastric bypass (MGB) (MD=−2.36%, 95%CI −4.13 to −0.58, P=0.009), duodenal-jejunal bypass liner (DJBL) (MD=−1.85%, 95%CI −2.75 to −1.96, P<0.000 01), sleeve gastrectomy (SG) (MD=−1.48%, 95%CI −2.49 to −0.47, P=0.004), and Roux-en-Y gastric bypass (RYGB) (MD=−1.31%, 95%CI −2.02 to −0.59, P=0.003). The effects of biliopancreatic diversion with duodenal switch and gastric plication were uncertain. Adjustable gastric banding and Roux-en-Y gastrojejunostomy had no significant effects on HbA1c. Because of the limitations of small sample size and high risk of bias, the results of SGTB requires further validation. Conclusions The current evidence suggests that the bariatric surgeries that have relatively beneficial effects for lowering HbA1c treatment are MGB, DJB, SG and RYGB in sequence.

Citation： ZHOU Xu, ZHU Weifeng, CHEN Xiaofan, YAN Dongmei, NIE Heyun, CHEN Jianrong. Network meta-analysis of effects of bariatric surgeries on hemoglobin A1c in overweight/obese patients with type 2 diabetes. Chinese Journal of Evidence-Based Medicine, 2020, 20(9): 1059-1068. doi: 10.7507/1672-2531.201912073 Copy

1.	Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism, 2018, 79: 97-107.
2.	Stegenga H, Haines A, Jones K, <italic>et al</italic>. Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ, 2014, 349: g6608.
3.	Menzo EL, Hinojosa M, Carbonell A, <italic>et al</italic>. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis, 2018, 14(9): 1221-1232.
4.	Wang FG, Yan WM, Yan M, <italic>et al</italic>. Outcomes of mini vs Roux-en-Y gastric bypass: a meta-analysis and systematic review. Int J Surg, 2018, 56: 7-14.
5.	Patel SR, Mason J, Hakim N. The duodenal-jejunal bypass sleeve (endobarrier gastrointestinal liner) for weight loss and treatment of type ii diabetes. Indian J Surg, 2012, 74(4): 275-277.
6.	Roslin MS, Cripps CN. Bariatric surgery in managing diabetes mellitus. Curr Opin Gastroenterol, 2016, 32(6): 481-486.
7.	Padwal R, Klarenbach S, Wiebe N, <italic>et al</italic>. Bariatric surgery: a systematic review and network meta-analysis of randomized trials. Obes Rev, 2011, 12(8): 602-621.
8.	WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet, 2004, 363(9403): 157-163.
9.	American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019. Diabetes Care, 2019, 42(Suppl 1): S13-S28.
10.	Guyatt GH, Busse JW. Tool to assess risk of bias in randomized controlled trials; 2017. Available from: https://www.evidencepartners.com/wp-content/uploads/2017/09/Tool-to-Assess-Risk-of-Bias-in-Randomized-Controlled-Trials.pdf.
11.	Higgins JPT, Churchill R, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 5.2.0, 2011. Available from: http://www.training.cochrane.org/handbook.
12.	王琪, 王韵华, 赖鸿皓, 等. 网状 Meta 分析证据质量分级: CINeMA 在线应用程序简介. 中国循证医学杂志, 2020, 20(9): 1111-1116.
13.	Azevedo FR, Santoro S, Correa-Giannella ML, <italic>et al</italic>. A prospective randomized controlled trial of the metabolic effects of sleeve gastrectomy with transit bipartition. Obes Surg, 2018, 28(10): 3012-3019.
14.	Casajoana A, Pujol J, Garcia A, <italic>et al</italic>. Predictive value of gut peptides in t2d remission: randomized controlled trial comparing metabolic gastric bypass, sleeve gastrectomy and greater curvature plication. Obes Surg, 2017, 27(9): 2235-2245.
15.	Cortez RV, Petry T, Caravatto P, <italic>et al</italic>. Shifts in intestinal microbiota after duodenal exclusion favor glycemic control and weight loss: a randomized controlled trial. Surg Obes Relat Dis, 2018, 14(11): 1748-1754.
16.	Courcoulas AP, Belle SH, Neiberg RH, <italic>et al</italic>. Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment: a randomized clinical trial. JAMA Surg, 2015, 150(10): 931-940.
17.	Cummings DE, Arterburn DE, Westbrook EO, <italic>et al</italic>. Gastric bypass surgery vs intensive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomised controlled trial. Diabetologia, 2016, 59(5): 945-953.
18.	Ding SA, Simonson DC, Wewalka M, <italic>et al</italic>. Adjustable gastric band surgery or medical management in patients with type 2 diabetes: a randomized clinical trial. J Clin Endocrinol Metab, 2015, 100(7): 2546-2556.
19.	Dixon JB, O'Brien PE, Playfair J, <italic>et al</italic>. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA, 2008, 299(3): 316-323.
20.	Ikramuddin S, Korner J, Lee WJ, <italic>et al</italic>. Lifestyle intervention and medical management with vs without Roux-en-Y gastric bypass and control of hemoglobin A1c, LDL cholesterol, and systolic blood pressure at 5 years in the diabetes surgery study. JAMA, 2018, 319(3): 266-278.
21.	Keidar A, Hershkop KJ, Marko L, <italic>et al</italic>. Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial. Diabetologia, 2013, 56(9): 1914-1918.
22.	Koehestanie P, de Jonge C, Berends FJ, <italic>et al</italic>. The effect of the endoscopic duodenal-jejunal bypass liner on obesity and type 2 diabetes mellitus, a multicenter randomized controlled trial. Ann Surg, 2014, 260(6): 984-992.
23.	Lee WJ, Chong K, Lin YH, <italic>et al</italic>. Laparoscopic sleeve gastrectomy <italic>versus</italic> single anastomosis (mini-) gastric bypass for the treatment of type 2 diabetes mellitus: 5-year results of a randomized trial and study of incretin effect. Obes Surg, 2014, 24(9): 1552-1562.
24.	Liang Z, Wu Q, Chen B, <italic>et al</italic>. Effect of laparoscopic Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus with hypertension: a randomized controlled trial. Diabetes Res Clin Pract, 2013, 101(1): 50-56.
25.	Mingrone G, Panunzi S, De Gaetano A, <italic>et al</italic>. Bariatric-metabolic surgery <italic>versus</italic> conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet, 2015, 386(9997): 964-973.
26.	Murphy R, Clarke MG, Evennett NJ, <italic>et al</italic>. Laparoscopic sleeve gastrectomy <italic>versus</italic> banded Roux-en-Y gastric bypass for diabetes and obesity: a prospective randomised double-blind trial. Obes Surg, 2018, 28(2): 293-302.
27.	Peterli R, Wölnerhanssen BK, Peters T, <italic>et al</italic>. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the sm-boss randomized clinical trial. JAMA, 2018, 319(3): 255-265.
28.	Rodriguez L, Reyes E, Fagalde P, <italic>et al</italic>. Pilot clinical study of an endoscopic, removable duodenal-jejunal bypass liner for the treatment of type 2 diabetes. Diabetes Technol Ther, 2009, 11(11): 725-732.
29.	Schauer PR, Bhatt DL, Kirwan JP, <italic>et al</italic>. Bariatric surgery <italic>versus</italic> intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med, 2017, 376(7): 641-651.
30.	Schouten R, Rijs CS, Bouvy ND, <italic>et al</italic>. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg, 2010, 251(2): 236-243.
31.	Simonson DC, Halperin F, Foster K, <italic>et al</italic>. Clinical and patient-centered outcomes in obese patients with type 2 diabetes 3 years after randomization to Roux-en-Y gastric bypass surgery <italic>versus</italic> intensive lifestyle management: The SLIMM-T2D Study. Diabetes Care, 2018, 41(4): 670-679.
32.	Tang Q, Sun Z, Zhang N, <italic>et al</italic>. Cost-effectiveness of bariatric surgery for type 2 diabetes mellitus: a randomized controlled trial in china. Medicine (Baltimore), 2016, 95(20): e3522.
33.	Tarnoff M, Rodriguez L, Escalona A, <italic>et al</italic>. Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve <italic>versus</italic> low calorie diet for pre-operative weight loss in bariatric surgery. Surg Endosc, 2009, 23(3): 650-656.
34.	Wentworth JM, Burton P, Laurie C, <italic>et al</italic>. Five-year outcomes of a randomized trial of gastric band surgery in overweight but not obese people with type 2 diabetes. Diabetes Care, 2017, 40(4): e44-e45.
35.	Yang J, Wang C, Cao G, <italic>et al</italic>. Long-term effects of laparoscopic sleeve gastrectomy <italic>versus</italic> Roux-en-Y gastric bypass for the treatment of Chinese type 2 diabetes mellitus patients with body mass index 28-35 kg/m<sup>2</sup>. BMC Surg, 2015, 15: 88.
36.	Yi B, Jiang J, Zhu LY, <italic>et al</italic>. Comparison of the effects of Roux-en-Y gastrojejunostomy and LRYGB with small stomach pouch on type 2 diabetes mellitus in patients with BMI<35 kg/m<sup>2</sup>. Surg Obes Relat Dis, 2015, 11(5): 1061-1068.
37.	Service GJ, Thompson GB, Service FJ, <italic>et al</italic>. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med, 2005, 353(3): 249-254.
38.	Guo Y, Liu CQ, Shan CX, <italic>et al</italic>. Gut microbiota after Roux-en-Y gastric bypass and sleeve gastrectomy in a diabetic rat model: Increased diversity and associations of discriminant genera with metabolic changes. Diabetes Metab Res Rev, 2017, 33(3).

1. Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism, 2018, 79: 97-107.
2. Stegenga H, Haines A, Jones K, <italic>et al</italic>. Identification, assessment, and management of overweight and obesity: summary of updated NICE guidance. BMJ, 2014, 349: g6608.
3. Menzo EL, Hinojosa M, Carbonell A, <italic>et al</italic>. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis, 2018, 14(9): 1221-1232.
4. Wang FG, Yan WM, Yan M, <italic>et al</italic>. Outcomes of mini vs Roux-en-Y gastric bypass: a meta-analysis and systematic review. Int J Surg, 2018, 56: 7-14.
5. Patel SR, Mason J, Hakim N. The duodenal-jejunal bypass sleeve (endobarrier gastrointestinal liner) for weight loss and treatment of type ii diabetes. Indian J Surg, 2012, 74(4): 275-277.
6. Roslin MS, Cripps CN. Bariatric surgery in managing diabetes mellitus. Curr Opin Gastroenterol, 2016, 32(6): 481-486.
7. Padwal R, Klarenbach S, Wiebe N, <italic>et al</italic>. Bariatric surgery: a systematic review and network meta-analysis of randomized trials. Obes Rev, 2011, 12(8): 602-621.
8. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet, 2004, 363(9403): 157-163.
9. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019. Diabetes Care, 2019, 42(Suppl 1): S13-S28.
10. Guyatt GH, Busse JW. Tool to assess risk of bias in randomized controlled trials; 2017. Available from: https://www.evidencepartners.com/wp-content/uploads/2017/09/Tool-to-Assess-Risk-of-Bias-in-Randomized-Controlled-Trials.pdf.
11. Higgins JPT, Churchill R, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 5.2.0, 2011. Available from: http://www.training.cochrane.org/handbook.
12. 王琪, 王韵华, 赖鸿皓, 等. 网状 Meta 分析证据质量分级: CINeMA 在线应用程序简介. 中国循证医学杂志, 2020, 20(9): 1111-1116.
13. Azevedo FR, Santoro S, Correa-Giannella ML, <italic>et al</italic>. A prospective randomized controlled trial of the metabolic effects of sleeve gastrectomy with transit bipartition. Obes Surg, 2018, 28(10): 3012-3019.
14. Casajoana A, Pujol J, Garcia A, <italic>et al</italic>. Predictive value of gut peptides in t2d remission: randomized controlled trial comparing metabolic gastric bypass, sleeve gastrectomy and greater curvature plication. Obes Surg, 2017, 27(9): 2235-2245.
15. Cortez RV, Petry T, Caravatto P, <italic>et al</italic>. Shifts in intestinal microbiota after duodenal exclusion favor glycemic control and weight loss: a randomized controlled trial. Surg Obes Relat Dis, 2018, 14(11): 1748-1754.
16. Courcoulas AP, Belle SH, Neiberg RH, <italic>et al</italic>. Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment: a randomized clinical trial. JAMA Surg, 2015, 150(10): 931-940.
17. Cummings DE, Arterburn DE, Westbrook EO, <italic>et al</italic>. Gastric bypass surgery vs intensive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomised controlled trial. Diabetologia, 2016, 59(5): 945-953.
18. Ding SA, Simonson DC, Wewalka M, <italic>et al</italic>. Adjustable gastric band surgery or medical management in patients with type 2 diabetes: a randomized clinical trial. J Clin Endocrinol Metab, 2015, 100(7): 2546-2556.
19. Dixon JB, O'Brien PE, Playfair J, <italic>et al</italic>. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA, 2008, 299(3): 316-323.
20. Ikramuddin S, Korner J, Lee WJ, <italic>et al</italic>. Lifestyle intervention and medical management with vs without Roux-en-Y gastric bypass and control of hemoglobin A1c, LDL cholesterol, and systolic blood pressure at 5 years in the diabetes surgery study. JAMA, 2018, 319(3): 266-278.
21. Keidar A, Hershkop KJ, Marko L, <italic>et al</italic>. Roux-en-Y gastric bypass vs sleeve gastrectomy for obese patients with type 2 diabetes: a randomised trial. Diabetologia, 2013, 56(9): 1914-1918.
22. Koehestanie P, de Jonge C, Berends FJ, <italic>et al</italic>. The effect of the endoscopic duodenal-jejunal bypass liner on obesity and type 2 diabetes mellitus, a multicenter randomized controlled trial. Ann Surg, 2014, 260(6): 984-992.
23. Lee WJ, Chong K, Lin YH, <italic>et al</italic>. Laparoscopic sleeve gastrectomy <italic>versus</italic> single anastomosis (mini-) gastric bypass for the treatment of type 2 diabetes mellitus: 5-year results of a randomized trial and study of incretin effect. Obes Surg, 2014, 24(9): 1552-1562.
24. Liang Z, Wu Q, Chen B, <italic>et al</italic>. Effect of laparoscopic Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus with hypertension: a randomized controlled trial. Diabetes Res Clin Pract, 2013, 101(1): 50-56.
25. Mingrone G, Panunzi S, De Gaetano A, <italic>et al</italic>. Bariatric-metabolic surgery <italic>versus</italic> conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet, 2015, 386(9997): 964-973.
26. Murphy R, Clarke MG, Evennett NJ, <italic>et al</italic>. Laparoscopic sleeve gastrectomy <italic>versus</italic> banded Roux-en-Y gastric bypass for diabetes and obesity: a prospective randomised double-blind trial. Obes Surg, 2018, 28(2): 293-302.
27. Peterli R, Wölnerhanssen BK, Peters T, <italic>et al</italic>. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the sm-boss randomized clinical trial. JAMA, 2018, 319(3): 255-265.
28. Rodriguez L, Reyes E, Fagalde P, <italic>et al</italic>. Pilot clinical study of an endoscopic, removable duodenal-jejunal bypass liner for the treatment of type 2 diabetes. Diabetes Technol Ther, 2009, 11(11): 725-732.
29. Schauer PR, Bhatt DL, Kirwan JP, <italic>et al</italic>. Bariatric surgery <italic>versus</italic> intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med, 2017, 376(7): 641-651.
30. Schouten R, Rijs CS, Bouvy ND, <italic>et al</italic>. A multicenter, randomized efficacy study of the EndoBarrier Gastrointestinal Liner for presurgical weight loss prior to bariatric surgery. Ann Surg, 2010, 251(2): 236-243.
31. Simonson DC, Halperin F, Foster K, <italic>et al</italic>. Clinical and patient-centered outcomes in obese patients with type 2 diabetes 3 years after randomization to Roux-en-Y gastric bypass surgery <italic>versus</italic> intensive lifestyle management: The SLIMM-T2D Study. Diabetes Care, 2018, 41(4): 670-679.
32. Tang Q, Sun Z, Zhang N, <italic>et al</italic>. Cost-effectiveness of bariatric surgery for type 2 diabetes mellitus: a randomized controlled trial in china. Medicine (Baltimore), 2016, 95(20): e3522.
33. Tarnoff M, Rodriguez L, Escalona A, <italic>et al</italic>. Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve <italic>versus</italic> low calorie diet for pre-operative weight loss in bariatric surgery. Surg Endosc, 2009, 23(3): 650-656.
34. Wentworth JM, Burton P, Laurie C, <italic>et al</italic>. Five-year outcomes of a randomized trial of gastric band surgery in overweight but not obese people with type 2 diabetes. Diabetes Care, 2017, 40(4): e44-e45.
35. Yang J, Wang C, Cao G, <italic>et al</italic>. Long-term effects of laparoscopic sleeve gastrectomy <italic>versus</italic> Roux-en-Y gastric bypass for the treatment of Chinese type 2 diabetes mellitus patients with body mass index 28-35 kg/m<sup>2</sup>. BMC Surg, 2015, 15: 88.
36. Yi B, Jiang J, Zhu LY, <italic>et al</italic>. Comparison of the effects of Roux-en-Y gastrojejunostomy and LRYGB with small stomach pouch on type 2 diabetes mellitus in patients with BMI<35 kg/m<sup>2</sup>. Surg Obes Relat Dis, 2015, 11(5): 1061-1068.
37. Service GJ, Thompson GB, Service FJ, <italic>et al</italic>. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med, 2005, 353(3): 249-254.
38. Guo Y, Liu CQ, Shan CX, <italic>et al</italic>. Gut microbiota after Roux-en-Y gastric bypass and sleeve gastrectomy in a diabetic rat model: Increased diversity and associations of discriminant genera with metabolic changes. Diabetes Metab Res Rev, 2017, 33(3).

Chinese Journal of Evidence-Based Medicine

Network meta-analysis of effects of bariatric surgeries on hemoglobin A1c in overweight/obese patients with type 2 diabetes

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